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Promoting a Collaborative, Informed Shared Decision Making Model

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Promoting a Collaborative, Informed Shared Decision Making Model Breastfeeding and Safe Sleep: Promoting a Collaborative, Informed Shared Decision Making Model Prepared by Tina Revai Approved by BC Lactation Consultants Association Board September 6, 2014 Abstract Members of the British Columbia Lactation Consultant Association (BCLCA) work closely with families in the real life world of infant care to help achieve breastfeeding goals. Our membership are concerned that there is a paucity of resources to support families in making the best decisions to support the intense nighttime care work of infants in a safe manner. We recommend a collaborative working group be established to review the evidence and consider the perspective of the healthcare consumer in the development of resources. 1.0 Background BCLCA is a non-profit organization whose members are dedicated to the promotion, support and protection of breastfeeding in our province. We are affiliated with the Canadian Lactation Consultant Association. Most (87%) but not all members hold the qualification of International Board Certified Lactation Consultants (IBCLC). Many of our members hold a second healthcare professional designation in addition to IBCLC, such as Registered Nurse, Registered Dietician, Medical Doctor or other professional qualification. We have members employed by each of the Health Authorities in British Columbia, although very few are directly employed as IBCLC’s. In most cases, IBCLC’s are employed primarily through their other professional designation and they have the additional responsibility of lactation support. In the spring of 2013 the BCLCA Board polled members to form our strategic plan. Sleep and breastfeeding was identified as a priority issue for BCLCA members. Specifically, members were concerned about conflicting messages regarding infant sleep in our province and the fact that much of this advice does not support the realities of families wishing to breastfeed. Most alarming was the experience shared by many members that the families they work with are adopting less safe sleep strategies in order to follow public health safe sleep advice. This is especially concerning given that many BCLCA members feel that their employer has limited them from having a proactive conversation about the interrelatedness of sleep and breastfeeding and the realities of nighttime infant care. 2.0 Breastfeeding in B.C. Current recommendations are that “breastfeeding - exclusively for the first six months, and sustained for up to two years or longer with appropriate complementary feeding - is important for the nutrition, immunologic protection, growth, and development of infants and toddlers” (Health Canada, 2014). Many other professional and health organizations have similar recommendations (Canadian Pediatric Society & World Health Organization). The Ministry of Health has identified Maternal Child and Family Health as a core program in BC’s Guiding Framework for Public Health (Ministry of Health, 2013). Breastfeeding has well-documented positive effects on the health of infants and mothers that fits under this goal. Breastfeeding promotion is a public health strategy that contributes to better health outcomes and has potential to reduce health inequities – an important mandate set by the Ministry of Health. Most women want to breastfeed their babies. In 2005, the rate for breastfeeding initiation was 97% (Public Health Agency of Canada, 2009), while the rate of exclusive breastfeeding upon discharge from hospital was only 69.5% for the same year (Perinatal Services BC, 2006). The decrease in rates from initiation to discharge suggests that the system that supports mothers and infants is not operating optimally. The literature supports the idea that the majority of mothers are not able to meet their own personal goals to breastfeed as long as they intend (Odom et al., 2013; Public Health Agency of Canada, 2009). Collectively, we all have responsibility to ensure that the healthcare system does not inadvertently block families in achieving their goals and indeed works to create a context that facilitates healthy behavior. Families and stakeholders value breastfeeding for a variety of important reasons, including health promotion of mother and babe in both the short and long-term (Horta et al., 2013; Hoddinott et al., 2008; Ip et al., 2009; Owen et al., 2002; Talayero et al., 2006; Zheng et al., 2000). 3.0 Sleep and Bedsharing Nighttime parenting is a considerable issue for all new mothers. Around the world and throughout history, the best solution to the challenges of attending to a young, vulnerable baby has been to sleep close to mother (Russell et al., 2013). It was not until quite recently, with the availability of formula and cribs, that prolonged separation at night was a viable option. Current Canadian recommendations regarding nighttime infant sleep state that is safest to have the infant in a crib in the parental room for the first 6 months of life (Canadian Pediatric Society, 2014). However, the Canadian Pediatric Society (CPS) also “acknowledges that some parents will, nonetheless, choose to share a bed with their child” (CPS, 2014). The CPS have summarized “what we know” from the best available evidence: • Sleeping on the back carries the lowest risk of SIDS • Room-sharing lowers the risk of SIDS • The risk of SIDS is increased when infants bedshare with mothers who smoke cigarettes • Bedsharing with an adult who is extremely fatigued or impaired by alcohol or drugs (legal or illegal) that reduce arousal can be hazardous to the infant • The use of soft bedding, pillows and covers that can cover the head increase the risk of death in all sleeping environments • Sleeping with an infant on a sofa is associated with a particularly high risk of sudden unexpected death in infancy • An infant is more at risk of sudden unexpected death if he/she bedshares with people other than his/her parents or usual caregiver (Level II-2, Grade B evidence – see appendix for more information on grading of evidence) The National Institute of Health & Care Excellence (NICE) in the UK has been updating its recommendations, which are currently on-line with the final guideline to be released December 2014. They have been looking at the relationship between bedsharing, what they call co-sleeping, and Sudden Infant Death Syndrome (SIDS). This is important, as the NICE draft review includes the results of a recent meta- analysis by Carpenter and colleagues (2013), which was an attempt to “resolve uncertainty as to the risk of SIDS associated with sleeping in bed with your baby if neither parent smokes and the baby is breastfed” wherein they suggested there is risk. This analysis has been met with significant controversy by other researchers, who have expressed concern over methodological, statistical and interpretational issues (Ockwell-Smith et al., 2013; Renz-Polster et al., 2013). Indeed, the results of an even more recent case control analysis come to a different conclusion, stating “there is no significantly increased risk for SIDS associated with bed-sharing in the absence of sofa-sharing, alcohol consumption and smoking” (Blair, Sidebotham, Pease & Fleming, 2014). The draft NICE guideline summarizes the issue as follows: “The cause of sudden infant death syndrome (SIDS) is not known. It may be that there are many factors contributing to SIDS . However, the evidence does not allow us to say that co-sleeping causes SIDS. Therefore the term ‘association’ has been used in the recommendations in this update to describe the relationship between co-sleeping and SIDS.” What adds to the confusion is that CPS and NICE documents use “bedsharing” and “co-sleeping” to describe the same thing: sleeping on the same sleep surface with an adult caregiver (CPS, 2014; NICE, 2014). This could be a North American style mattress and box spring, a futon on the floor, or a couch. Confusion persists in the sleep research, as there are different terms and definitions used to describe a variety of sleep situations. However our preliminary knowledge informs us there are very different risks associated with each of the described sleep environments. For example, CPS clearly states that “sleeping with an infant on a sofa is associated with a particularly high risk of sudden unexpected death in infancy”. In our experience working directly with families, parents continue to sleep with their infants for a variety of reasons, both intentionally and unintentionally. Although we have no accurate measure of the rate of bedsharing in BC, data collected from 1, 867 Oregon mothers in 1998/1999 looked at sleep arrangements and found that 76% of mothers reported bedsharing at least some of the time (Lahr et al., 2007). This is consistent with the results of a survey of 1,122 mothers in Manitoba, where researchers found that 72% of mothers reported bedsharing on a regular or occasional basis (Ateah et al., 2008). Most alarming is that many of our members report that families say they are sofa sleeping due to fears regarding falling asleep with the infant in the parental bed. We have no direct BC data, but this is consistent with a 2008 survey of 4,789 American mothers where researchers found that 25% of mothers admit to having fallen asleep while breastfeeding their infants on chairs, sofas or recliners (Kendall- Tackett et al., 2010). These findings align with SIDS research collected over a 20 year period in the UK. Blair and colleagues did a case control study of 300 SIDS deaths from 1984 to 2003 and it was noted there was an increase in the number of deaths of infants sleeping with a parent on a sofa (Blair et al., 2006). Therefore, despite what has historically been a well-intended predominantly anti- bedsharing message to parents, mothers continue to sleep with their babies at night. In some situations this occurs out of desperation to settle the infant, in others it is a cultural or value driven approach to nighttime care. Still, in other situations it is that real choice is constrained by socioeconomic realities, e.g.
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